Safe and Effective Surgery for Endometriosis Including Detection and Intervention for Ovarian Cancer

(1)

Safe and Effective

Surgery for Endometriosis

Including Detection and Intervention for

Ovarian Cancer

Camran

Camran NezhatNezhat, MD, FACOG, FACS, MD, FACOG, FACS Stanford University Medical Center Stanford University Medical Center

Center for Special Minimally Invasive Surgery Center for Special Minimally Invasive Surgery Palo Alto, CA 94304

Palo Alto, CA 94304 camran@nezhat.org camran@nezhat.org

(2)

Introduction and Overview

•

• This talk aims to provide an overview of

This talk aims to provide an overview of

safer surgical techniques for the

treatment of endometriosis as well as

review the literature on ways to

maximize the effectiveness of surgery

for recurrence prevention and fertility.

Included is a discussion of detection

and intervention for ovarian cancer in

the patient with endometriosis.

(3)

Outline

•

• Background on Surgery for Endometriosis

Background on Surgery for Endometriosis

•

• Safer Surgical Technique

Safer Surgical Technique

•

• Optimizing Effectiveness of Treatment

Optimizing Effectiveness of Treatment

•

• Endometriosis and

Endometriosis and

Infertiltiy

•

(4)

Surgical Treatment of

Endometriosis

•

• Indications for surgery

Indications for surgery

–

Diagnostic

–

Severe endometriosis

–

Failed medical management

–

Infertility

•

• Options

Options

–

(5)

Surgical Treatment of

Endometriosis

•

• Definitive Surgery:

Definitive Surgery:

–

Removal of uterus, ovaries, and tubes

•

• Conservative Surgery

Conservative Surgery

–

Ablation versus excision of implants and

adhesions

–

(6)

Conservative Surgery

•

• Excision, fulguration, or laser

Excision, fulguration, or laser

vaporization of

endometriotic

implants

•

• Removal of adhesions

Removal of adhesions

•

• Resection of

Resection of

endometriomas

including the cyst wall

•

• Restoration of normal pelvic

Restoration of normal pelvic

anatomy

(7)

Conservative Surgery

•

• Ancillary procedures:

Ancillary procedures:

–

Presacral

neurectomy

–

Uterosacral

neurectomy

(8)

Maximizing Safety in Surgery

•

• Identifying

Identifying

Landmarks

•

• Ureterolysis

Ureterolysis

•

• Hydrodissection

Hydrodissection

and CO2 Laser

–

More precise and

less penetrating

(9)

Maximizing Safety in Surgery

•

• Cystoscopy

Cystoscopy

,

Proctoscopy

–

Check integrity if ablation/fulguration are

done around bladder or bowel

•

• Recognizing when consultation is

Recognizing when consultation is

needed

(10)

Optimizing Effectiveness

•

• Recurrence risk

Recurrence risk

–

Risk of recurrence is estimated to be as

high as 40 percent at 10 year of follow up

•

• Pain control

Pain control

–

Pain relief is achieved in most patients

who undergo ablation/resection of

endometriosis

(11)

Optimizing Effectiveness

•

• Randomized trials

Randomized trials

•

• Trial 1

Trial 1

–

LSC laser ablation of endometriotic

LSC laser ablation of

endometriotic

implants

plus uterine nerve ablation was more likely to

result in improvement or resolution of

symptoms at 6 months than expectant

management (63 versus 23 %)

•

• Women with stage I disease were less likely to

Women with stage I disease were less likely to

improve after their surgical procedure

(12)

Optimizing Effectiveness

• Trial 2

Trial 2

–

LSC excision of implants led to symptomatic

improvement in 80% of patients at 6 months

compared to 32% of controls undergoing

diagnostic laparoscopy

•

• Most of these women had stage II-

Most of these women had stage II

-

IV disease which

may account for higher success rate

(13)

Optimizing Effectiveness

•

• Combining LSC laser ablation,

Combining LSC laser ablation,

adhesiolysis

and uterine nerve ablation is

likely to be beneficial treatment for pelvic

pain associated with minimal, mild and

moderate endometriosis

–

Interpret with caution

-

only one trial in this

Cochrane review

(14)

Optimizing Effectiveness

•

• Presacral

Presacral

Neurectomy

–

Insufficient evidence to recommend use of

nerve interruption in the management of

dysmenorrhea

alone

•

• Our clinical experience: shows efficacy

Our clinical experience: shows efficacy

(15)

Optimizing Effectiveness

•

• Barrier agents for preventing

Barrier agents for preventing

adhesions after surgery for

subfertility

–

Interceed

reduces incidence of adhesion

formation but insufficient data to support

its use to improve pregnancy

–

Seprafilm

no evidence in prevention of

adhesion formation

(16)

Optimizing Effectiveness

•

• Pre and post operative medical therapy for

Pre and post operative medical therapy for

endometriosis surgery

–

Cochrane Review showed insufficient evidence that

hormonal suppression in association with surgery provides

improvement of symptoms, pregnancy rates and overall

tolerability but a significant improvement in disease

recurrence

(17)

Treatment of Infertility

•

• Endometriosis can reduce

Endometriosis can reduce

fecundability

•

• Endometriosis does not usually completely

Endometriosis does not usually completely

prevent conception

(18)

Treatment of Infertility

•

• Achieving pregnancy

Achieving pregnancy

following a surgical

procedure depends on:

–

stage of disease

–

presence of other

infertility factors

•

• Women with moderate

Women with moderate

to severe endometriosis

who desire pregnancy

benefit from surgical

therapy

(19)

Treatment of Infertility

–

Pregnancy rates after surgery:

•

• Moderate endometriosis 50%

Moderate endometriosis 50%

•

• Severe endometriosis 39%

Severe endometriosis 39%

–

Pregnancy rates with expectant

management:

•

• Mild 50%

Mild 50%

•

• Moderate <25%

Moderate <25%

•

• Severe disease 5%

Severe disease 5%

Evers 1989

(20)

Cancer Risk and Endometriosis

•

• Epidemiologic evidence

Epidemiologic evidence

–

Large cohort studies suggest

endometriosis is an independent risk

factor for epithelial ovarian cancer (EOC)

–

Risk of malignant transformation in

ovarian endometriosis is approx 2.5%

(21)

Cancer Risk and Endometriosis

•

• Endometrioid

Endometrioid

and

clear cell ovarian

cancer can arise from

endometriomas

(22)

Cancer Risk and Endometriosis

•

• Endometriosis associated ovarian cancer

Endometriosis associated ovarian cancer

presents:

–

Earlier stage

–

Lower grade lesions

–

Better overall survival 81%

vs

54%

•

• Ovarian

Ovarian

endometrioid

and clear cell cancer

more commonly diagnosed in Stage 1

because of their frequent association with

symptomatic endometriosis

Erzen et al Oct 2001

(23)

Cancer Risk and Endometriosis

•

• Molecular studies detected common

Molecular studies detected common

alterations in endometriosis and

ovarian cancer

•

• Risk of ovarian cancer is highest in

Risk of ovarian cancer is highest in

women with endometriosis and primary

infertility

Brinton et al Aug 2004 Van Gorp et al Apr 2004 Nezhat, F 2005 abstract

(24)

Cancer Risk and Endometriosis

Screening

•

• No Standardized

No Standardized

Protocol

•

• Screening

Screening

–

Routine annual exam

–

Clinical symptoms

–

Ultrasound if needed

–

Tumor markers if

indicated

(25)

Cancer Risk and Endometriosis

Detection

•

• Consider washings

Consider washings

•

• Consider frozen

Consider frozen

section

•

• Prepare patient for

Prepare patient for

full staging if index

of suspicion is high

(26)

Thank you

Camran

Nezhat

, MD, FACOG, FACS

Center for Special Minimally Invasive Surgery

Stanford University

(27)

Bibliography

•

• Abbott, J et al. Laparoscopic excision of endometriosis: a randoAbbott, J et al. Laparoscopic excision of endometriosis: a randomized mized placebo

placebo--controlled trial. controlled trial. FertilFertil SterilSteril 2004; 82:878.2004; 82:878.

•

• BrintonBrinton, LA, et al Ovarian cancer risk associate with varying causes of, LA, et al Ovarian cancer risk associate with varying causes of infertility.

infertility. FertilFertil SterilSteril 2004 Aug; 82(2): 4052004 Aug; 82(2): 405--14.14.

•

• Evers, JL. The pregnancy rate of the noEvers, JL. The pregnancy rate of the no--treatment group in randomized treatment group in randomized clinical trials of endometriosis therapy.

clinical trials of endometriosis therapy. FertilFertil SterilSteril. 1989; 52:906.. 1989; 52:906.

•

• ErzenErzen, M. Endometriosis, M. Endometriosis--associated ovarian carcinoma (EAOC): an entity associated ovarian carcinoma (EAOC): an entity distinct from other ovarian carcinomas as suggested by a nested

distinct from other ovarian carcinomas as suggested by a nested casecase- -control study.

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• FarquharFarquhar, C et al. Barrier agents , C et al. Barrier agents fforffor preventing adhesions after surgery for preventing adhesions after surgery for subfertility

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•

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•

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distribution of histologichistologic pattern. The Mount Sinai School of Medicine, New pattern. The Mount Sinai School of Medicine, New York, NY. USA Abstract P

(28)

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• NezhatNezhat, F. , F. SchlosshauerSchlosshauer, P. Analysis of BRAF/ERK and P16 in ovarian , P. Analysis of BRAF/ERK and P16 in ovarian endometrioid

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•

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•

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